Infectious Disease

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Robert Pa:cton PA-C, M.P.A.S.

Robert Paxton graduated from the University ofNebraska-Lincoln with a Bachelor's degree in biology, which was followed by two years of infectious disease research and teaching microbiology. He received his Masters of Physician Assistant Studies from Marquette Universrty. He currently works for a private infectious disease practice at St. Joseph's Regional Medical Center in Milwaukee,'WI. Mr, Paxton is an adjunct clinical professor and clinical preceptor for Marquette University, where he teaches a series of lectures on infectious disease. He is a member of the American Academy of Physician Assistants (AAPA) and the Wisconsin Academy of Physician Assistants (V/APA).

CME Resources Certification & Recertification Exam Review

Certifrcation & Recertification Exam Review CME Resources

Infectious Disease Topics Robert Paxton PA-C, MPAS
i)Selected f@Eections -Know the etiology, presentatior5 evaluation, and treatment -Ei$spl4smosis -Blastomycosis -eoscidioidomycosis -Pneumocystosis

r-eSplococcus -AErgillosis
-Candidiasis
2) Selected

fulozoal[shc]tions

-Know the etiology, presentation, evaluation, and treatment -Bebeliosis -Malaria -T6-ropiasmosis
3)Selected Yiral Iq&ctions -Know the etiology, preser$ation, evaluation, and treatment -Human Hslpesviruses

-!MV

-roIV-8

-vzv

-Iff

-Rabies -Sin Nombre Virus (Hantavirus)

-Severe Acute Respiratory Syndrome

-Igst Nile Virus

4) Selected

Brcketlsial Infeqtions -Know the etiology, presentation, evaiuatioq and treatment -Rocky Mountain Spotted Fever (Rickettsia) -Eillichio s is (E hr I i chi a)

5) S elected

Bacterial Infections -Know the etiology, presentatioq evaluation, and treatment -Tetanus -Botulism -Lyme Disease

6)Selected "@gJoos" -Know the etiology, presentation, evaluation, and treatment -Anthrax

-Suu[Po*
7) Selected

Sexuaiiy Transmitted Diseases -Know the eti6G,ffintation, evaluatiorq and treatment -Bacterial Vaginosis - Trichomonal Vaginitis -Chlamydial Urethritis / Cervicitis -Lyrnpho granuloma venereum -Gonorrhea

-}IPV
-HSV -Chancroid
-Granuloma inguinale -Syphilis -Molluscum Contagio sum -Pelvic Inflammatory Disease
8) S

elect ed

O&redic.l*nfections

-Know the etiology, presentation, evaluation, and treatment -Osteomyelitis -Infectious arthritis

9)Selected Cardiac Infections -Know the etiology, presentatiorl evaluation, and treatment - Spontaneous Bacterial Endocarditis -Rheumatic Heart Disease -Pericarditis
1

0) Seiected

Neurolo gicai Infections -Knowffilogy, presentation" evaluation, and treatment -Meningitis -Encephalitis

1l)Selected Skin & Soft Tissue Infections -Know the etiology, presentation, evaiuation, and treatment -Erysipeias -Cellulitis -Cutaneous abseesses (folliculitis, furuncles, carbuncles) -Necrotizing soft tissue infections (necrotizing fasciitis, Fournier' gangrene, clo stridial myonecrosis) -Bite wound infections

'

2)

elected Etiolo gies of Infectious Diarrhea

-Know the etiology, presentation, evaluatiorq and treatraent -Non-Inflammatory Diarhea -Viral infections (Norwalk Virus, Norovirus) -Protozoal infections (Giardia, Cryptosporidium) -Bacterial infections (5. aureus, B. cereus, V. cholerae) -Inflammatory Diarrhea -Protozoal infections (8. hi stolytic a) -Bacterial infections (E. coli 0157:H7, C. dfficile, Shigella, Campyl obacter, Salmonella)

Staphylococcus
Coaoulase positive S, aureus Coaoulase negative

Streptococcus
5. pneumoniae Lancefieid orouos
Group A: S. pyogene Group Bz S, agalactiae Group C Group D: S, bouis Group F Group G

S. epidermidis
S, saprophytras

Strep viridans

Notes: Group A (5. pyogenu\ strep throat, necrotizing fasciitis f'flesh-eating bacteriaf, rheurnatic heart disease Group B (5. agaladiae): perinalal strep, colonizer of vaginal canal, neonatal sepsis Group C, F, G: Not as commDn as Group A, B, and D Group D: used to include enteromccus, now ju$ .1liarzrs, If found in blood is thought to indicate colon cancer Strep viridans: 5, millen, S. anginosis, S. sativariuslEhrtis found in mouth, teethjupper respiratory tmct. Associated with endocarditis

Respiratory
Haemophilus influenzae

Non-Fermenters
Pseudomonas

Monxella ahrrhalis

-"

Enterics

Aanetobacler
Stenotrophomonas

..

* Proteus
Klehsiella

E mli

Enterubader Seratia
Salmonella
Yersinia

Crtrobader Shigella

vaqinitis
Vaginal pH @ 4.0 (Lactobacillus)

f UrS",\
Candida albicans

Trichomonas vepinalis
Manifeststions

Bacterial vaginosis

Cervicitis
Less

Yellow-Green DiC
Frothy D/C Copious D/C Malodomus D/C "Strawberrv vasina" > 5.5 -5.0 Motile richomonads on NaCI slide

GralshDlC
Homogeneous D/C Occ. Frothy DiC

Pruritus

D/C(D

Erythematous vulva
and vagina Thick/Crcamy D/C Dvsnareunia

MucopumlentD/C
Sponing
after intcrcourse 7.4

pH

>

4-5

WetMount

-4-7

<4.5
Sporcs urd Hyphae on KOH Moderare WBCs

ManyWBCs

"Clue Cells" [stippled epithelial cellsl FewWBCs

-#fz

lfany WBCs-. *
No orEsntsms On lifet MouaB

@Tirt6-st", Amme odor

KOH aoolied

when

i-

cenrEeErEs

{ G- , \

80 ToAsymptomatic Purulentvaginal D/C Dysuria

80%Asymptomatic Cervicitis
Urethral syndrome

HSY-Z:
tFever *Malaise

Fint episode - worst

*Headache

&5-90Yo

Primary
Chancre (l-5 wks) Secondary
Rash

PID
PharyngitiVArthritis

PID
Conjunctivitis

*Mlalgias

Lymphadenopathy Condyloma lata

Tertiary 6 -20 yrs) CV; gNS Intracellular (columnar/transitional)

Tzanck smear

Cultures

DNA probc;
(Urine LCR/PCR)

DNAprobc I Gm po

Acyclovir or
Famciclovir or

f;-ithromrcin Ciprofloxacin 500mg po

Doxycycline l00mg

Penicillin G+/Tetrarycline Jarisch-Heaheimer Febrile reaction

PCN Tx

Valcyclovir
+Suppressive Tx:

,,or:=,, \a$sxackf
PLUS

BID X
400mg Po

7 days

6)Vyear;

Note: Genital Ware Condyloma accuminata (Human Papillomavirus) Pink to white "frondlike" Issions; solitary or in clusters Associated cervical dysplasia (HPV 16, 18, 31, 35)

Overview of Infectious Disease

-Selecte(Fungallnlectron\ "

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-linked to bird droppings or bat guano exposure along Ohio River Valley -most infections are asyrnptomatic pulmonary infections --disserninated disease common in AIDS / immunocompromised states -diagnose with biopsy and urinary testk -treat with amphotericin B products or itraconazole J's-q*r:;;:t" I'r'r''a'' Sv*rh*

O":i - [r ,\t-u- n;,ilr 2)Blastomycosis -caused by Blastomyce s dermatitidis -linked to soil exposure along Ohio River Valley, especialiy dust exposure L (construction or excavation) 'L"\*c,r-' ! r 1:r"dhn 'frf,rt''ut*'r;14 -most infections are asymptbmatic puhngnary infectio* -disseminated disease cornmon in AIDS / immunocompromised states -diagnose with biopsy and culture -treat with amphotericin B products or itraconazoie

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3)Coccidioidomycosis 'caused by Coccidioides immitis -linked to geographical exposure history (southern California -> Texas) -called San Joaquin Valley Fever -40% present with influenza-like illness
-erythema nodo sum common with serology -treat with amphotericin B products
-diagnose

k3lPneumocystosis r
-caused by Pneumocystis

jiroveci

k
(calrtntt for boards)

-common n ruOS (< ZOO ) / immunocompromised states -present with fever, dyspnea, nonproductive cough -physical exam not usualiy consistent with degree ofhypoxemia -diagnose with CXR (interstitial infiltrates), sputurn, or bronchoscopy -treat with TMP-SI/D( or atovaquone -use prednisone if PaOz <7A mmHg

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4)Cryptococeus -caused by Cryptococcus neoformans -common in AIDS / immuqgco_mpromised states

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-may present with altered mental status changes, headache, or meningismus -diagnose with CSF and serum serology

-India ink may be positive -treat with amphotericin B products or fluconazole

S)Aspergillosis
-caused

lspergillus fumigatu, mostiy -many disease entities -allergic bronchopulmonary aspergillosis, aspergiliom4 and invasive aspergillosis -invasive aspergillosis most common in patients with prolonged neutropenia diagnose with tissue biopsy -treat with amphotericin B products or voriconazole

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6)Candidiasis -corrmon normal flora but opporlunistic infection possible . ,1r.,r) il,;tt,"t -categorized as C. albicans or non-albicaf Canafia--_=). \.: lc1 1'-sibr''\ -diagnosis of invasive disease requires tissue biopsy or evidence of retinal disease -C. albicans responds to fluconazole -non-albicans Candida may respond to fluconazole (some species are resistant)
-vaginal candidiasis -presents with wlvar itching. ery4hema. and white. cwdy discharge -KOH shows hlphae -treat with cream X 1-7d or fluconazole 100-200 mg PO

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-esophageal candidiasis -may present with substernal odynophagia, GE reflux, or nausea with or without substernal pain ptt;'"L\ -diagnose wirh EGD (with biopsy)

vety

-treat with fluconazole

-other Candidal diseases -Candidal funguria -Candidalfungemia(oftenline-associated) -choreoretinitis / endophthalrnitis -hepato splenic candidiasis -endocarditis

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-Selected Protozoal lnfections 1)Babesiosis -caused by Babesia microti -same distribution and transmission as Lyme disease -Dresents as'North American Malaria"

2)Malaria
-caused by Plasmodiury-ygg*2-_ryalariae, P. ovale, P.
-P.

falciparu4lqgs!:yizulelr}= Fa\ crp.ri*r

falciparum trr.:cixc\

-most common in tropical regions (travel history) -transmitted by female Anopheles mosquito -presents with periodic chills -> fever -> sweats -qod (tertian) with P. vivax, P. ovale, P. falciparum -q3d (quartan) with P. malartae -may also have FIA, myalgi4 splenomegaly -anemia and leukopenia common -diagnose with thick / thin blood smears = -prophylaxis for travelers vital .t'-.ir -chloroquine (if no P. falciparum resistance in travei area) iX, tr r'(rv."h\ c'. rJcis'n\ -mefloquine, doxycycline, atovaquone, or primaquine (if P. falcip arum J resistance) -treatment depends on piasmodium species and resistance in travel area

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3)Toxoplasmosis kt,)s

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Uter\

-transmitted by eating contaminated food, or handling cat litter -usually an asymptomatic primary infection -reactivation in AIDS (< 100 CD4 eells) / immunocompromised states -present with progressive HA, AMS changes, or new-onset seizure -diagnose with serology, biopsy, imaging -head CT shows ring-enhancing mass lesions -treat with pyrimethamine and sulfadiazine
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STDs -Herpes Simplex Virus 1& 2 (HSV) -Varicella Zoster Virus (VZV) -Chickenpox Peds ID -Herpes Zoster (Shingle$ (EBV) + ENT -Ebstein-Barr Virus ID -Cltomegalovirus (CIvfD Peds -Human Herpes Virus 6 (HHV-6) -etiology of roseola (exanthema subitum) -Human Herpes Virus 7 (HHV-7) Peds -? etiology of roseola (exanthema subitum) also -Human Herpes Virus 8 (HHV-8) ID -? etiology of Kaposi's sarcolna

) )

2)Herpes Zoster (Shingles) -caused by VaricellaZoster Virus (VZY -transmission is mostly respiratory, but direct contact with vesicular or pustular initial infection lesions may result in transmission -primary infection is chickenpox! -VZV remains dorrnant in dorsal root ganglia of nerve reactivation shingles disease -shingles tends to occur as people age and cell-mediated immunity wanes shingles in a patient <50 yrs. should make you consider HIV infection -presentation typically prodromal qanptoms (burning, tingling) in region of vesicular eruption typically of 1-3 dermatomes sensory nerve distribution -may disseminate in immunocompromised patients -recurrent vesicular outbreaks in the same spot HSV (more likely) -post-herpetic neuralgia is the most common long-term complication -clinical diagnosis followed by Tzanck smear / immunofluorescent antibody

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staining -treatment -cyclovir (PO) -miid to moderate disease -severe disease acyclovir (IV)

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3)Cytomegalovirus -caused by Cytomegalovirus (CIvIV) -transmission is sexual, congenital, transfusio4 transplantation and person-toperson (respiratory secretions) -primary infection presents similar to infectious mononucieosis -especialiy severe in AIDS (< 50 CD4 cells) / immunocompromised states -CMV retinitis (blindness) 'GI CMV (ulcers esophagus -> anus) -Pulmonary CMV ("pneumonia") -diagnose with PCR and biopsy -_ c:"fr\ v PC il* \ ettlt -treat with gangiclovir

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3)Hrrv-8
-causes Kaposi's sarcoma

-present

with red-purple macules, papules, nodules, or patches, throughout the

body -comrnon inAIDS patients /CIA ",.oJ,lca'., -treat by trying to reconstitute the immune system

Acjn

4)Rabies
-caused by a rhabdovirus

(:ar'n -noirodents / lagomorpfrs traUUitsl ^;"1 -""t-;;;; crith,;*re'L"c-usually there is a bite history -scratches from rabid animals are 50x less Iikely to transmit rabies

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owed by paresthesias -later manifestations include extreme behavior, convulsions, and seizures -prevention is the goal
.

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5)Sin Nombre Virus
-causes Hantavirus Pulmonary Syndrome -most cases in "Four-Corners" states

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-transmitted by inhalation of rodent urine / feces -present with flu-like illness, foliowed quickiy by shock and ARDS -treat with ?? (? ribavirin)

6)Human Immunodeficiency Virus -Epidemiology

-arr)'one who is sexuall)' active or injects drugs is at risk for HIV infection -in the US, HIV 1$ seen in gay merq then IVDU, blood transfusion recipients, and hemophiliacs -globa[y 35-40 million infected (most in developing countries)

-HiV

is a retrovirus -uses reverse transcriptase

to change viral RNA -> viral DNA

-Acute HIV Syndrome -"mononucleosis-like illness" usually more severe and more likely to need hospitalization -rash 40-80o/o (no exposure to aminopenicillins) -mucocutaneous ulceration is distinctive feature ',n J'h Scrna,i -diagnose RNA*I (viral i FjY -treat with HAART l+ tVr- rfpn^qLnL l)rtrrrr ettr 1nUCr6' ACtif Y^rix ilei ni'r\'|i'ru rtr" i<i;'lc 'n -HIV testing methods 4"71i"\y affstrcet -ELISA= srreeningtest -WB confirmatory -ELISA + wB {ge2lesg4qt -HIV viral load (measures copies/ml) -don't use as screening tool (unless AHS suspected) -used to test for neonatal HIV

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Symptomatic HIV infection -CD4 count and disease risk - >500 (lymphadenopathy) -200-500 (pulmonary TB, bacterial pneumonia, herpes zoster, NH-lymphom4 Kapo si sarcoma) -100-200 (PCP) - 5 0- 1 00 (CIvIV retinitis, toxoplasmo sis, cryptococcus) - <50 (MAC, CNS iymphom4 PNtr-)

-Antiretroviral options
-nucleoside reverse llnnscriptase inhibitors (NRTIs) -zidovudine (AZT), lamivudine (3 TC), enrtricitabine (FTC), didanosine (ddl), zalcitabine (ddc), stavudine (d4T), abacavtr (ABC), tenofovir -non-nucleoside reverse transcripase inhibitors $INRTIs) -nevirapine, delavirdine, efavirenz -protease inhibitors (PIs) -saquinavir, ritonavir, indinavir, nelfnavir, amprenavir / fo samprenavir, lopinavir, atazarovu -fusion inhibitors (enfuviride I T-20)

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-Antiretroviral Ciass Specific SE -NRTis -AZT: bone uvurow suppression -ddl, ddc, d4T : peripheral neuropathy / pancreatitis -ABC = hypersensitivity r>ar. (never rechallenge) -NNRTIS -all cause rash -efavirenz causes CNS disengagement (vivid dreams)
-PIs

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-all cause NAIID and "lipodystrophy / metabolic -indinavir causes nephrolithiasis a* s\)\6(

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-Highly Active Antiretroviral Therapy G{AART) -combination therap), with 3 drugs is standard of care -druss of choice

(-zNRtts+1PI\

-2NRTIs+lNNRTI
-2 NRTIs * abacavir -1 NRTI + 1 NNRTI +1 PI

-Opportunistic infections requiring prophyiaxis -pneumocyctosis (CD4 < 200) -TMP-SlvD( -toxoplasmosis (CD4 < 100) -TMP.SVD( -Myeobacterium avium compiex (CD4 < 50) -azithromycin or clarithromycin -HIV and pregnancy -ACTG 076 reduced transmission rate from 23% -> 8% (66% reduction) -Protocoi 1)PO AZT 100 mg 5x/d at week 14 until onset of labor 2 mgkg load, then 1 mg&g until delivery 3)8-12 hrs. after birth give AZT syrup 2 mgkg q6 for the 1$ 6 weeks of life

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7)Severe Acute Respiratory Syndrome (SARS) -caused by a "new" coronavirus (SARS-CoV) -transmitted by respiratory secretions & fomites -most cases in Hong Kong, Singapore, Hanor, and Toronto -presents with IJRTI qrrnptoms dry cough and hypoxemia -diagnose clinical picttxe plus risk factors -treatment is multifactorial

-CAP treatment + ribavirin

steroids

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8)West Nile Virus -WNV is a Arbovirus -WNV is in the family Flaviviridae -ls case in US + NYC '99 ->3000 cases with>170 deaths -WNV predominately spreads b/t birds and mosquitos -humans / other mammals are "dead-end" hosts -most will have an asym,ptomatic or mild viral illness -1 in 5 deveiop a mild febrile illness -1 in 150 develop meningitis, encephalitis, or both -present with meningitis / encephalitis Bc<,,'{ iYPt' 57rr -muscie weakness flaccid paralys -diagnose with CSF studies -IgM antibody capture ELISA for WNV Ly,'p,nirt vfr"- "{w ^'e-i$ij -fiert?2 (? Ribavirin + interferon a2b) -* 5r5 P* '''lY F\ rttr

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-Selected Rickettsial Infections l)Roclry Mountain Spotted Fever (RMSF) -caused by Rickettsia rickettsii -transmitted by tick bite -presents as "influenzal" prodrome, followed by F/C, HA, myalgias -red macular rash appears b/t 2od -> 6th da]t of fever. 1$ on the wrists and ankles and then spreading centrally treat with doxycyciine

L,ORrtj-\

+ Aroxut L

2)Ehrlichiosis -Ehrlichia chaffeenis causes human monocytic ehrlichiosis (HME) -transmitted by Lone Star Tick - Ehrlichia phago cyt ophila causes human granulocytic ehrlichio sis (HGE) -llansmitted by Ixodes bite -presents iike RMSF, except the rash is less cofirmon -rash involves trunk, spares hands / feet -diagnose with leukopenia, thrombocytopeni4 and elevated ALT / AST -treat with doxycycline

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-Selected Bacterial Infections

-caused by a neurotoxin elaborated by Clostridium tetani -associated with puncture wounds, but any wound is prone (iaceration, decubiti,

etc.) -frequently present withjaw or neck stiffiress and dysphagia -h;perreflexia and muscle spasm iater -jaw muscle spasm = trismus -prevent with vaccination +/- TIG -treatment (actual infection) -Td + TIG + Penicillin G 24 mu/d

2)Botulism

-caused by a neurotoxin elaborated by Clostridium \Z rno's ) -associated with home-canned food products and honey (infants) /up -present with sudden onset of dipiopia, dry moutlr, dysphagia, dysphoni4 and muscle weakness -> respiratory paralysis -treat witir6--_t6)

botulinum

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3)Lyme Disease
-caused by

Botelia burgdorferi

-common in NE and upper midwest and transmitted by tick bite -chamcterized in stages l)Early infection: Stage 1 (localized infection) -eMhema chronicum migrans (60-80% of cases) -small red papule -> centrifugal spread -> central clearing -F/C, myalgias / artlralgias, fatigue common 2)Early infection: Stage 2 (disseminated) -neurological synptoms (Bell's palsy) -cardiac s;nnptoms (AV block) 3)Late infection: Stage 3 (persistent) -chronic arthritis (monoarticular or asymmetric oligoarticular involving large joints) -diagno se with serology -treat with doxycycline, ceftriaxone, or amoxiciliin depending on stage

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-Selected

1)Anthrax

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-caused by Bacillus anthracis -transmitted naturaliy via exposure to infected animals or via inhaiation
as "bioweapons"

of spores

-tlrree fonns of antlrrax

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i)cutaneous (most commoq e4posure to wool) 2)GI (very rare, eating undercooked contaminated meat)
3

)inhalational (mo st deadiy)

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-Inhalational anthrac -usually present with flu-iike illness -inhaled spores cause mediastinitis / hemorrhagic l].mphadenitis -widened mediastinum on CXR -usually do not present with pneumonia -treat with ciprofloxacin and vaccinate

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2)Smallpox
-caused by Variola major

-eradicatedfr;;i*;iigao * \cr;t c*se-

rv-'' Crzrrr'rt?''

-transmitled by respiratory secretions and cutaneous contact -presents as flu-like illness, followed by rash (oral mucos4 face, UE / LE -> spreads centraliy to the trunk) 'lesions proeress from macules -> papules -> vesicles -> eschars (all in same stage of development) \ t-c -treat with ?cidofovir and vaccinate others ' 'ito|b\l'nle'i-S -r-ft'agg.\

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6F-' tre"rr'tJ F.*trd Sr4re' Transmitted Infections l)Bacterial Vaginosis

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-pollrnicrobial vaginal infection ) not felt to be a STI -an overgrowth of Gardnerella vaginalis and other anaerobes
-ctue celts are epitneUal c -associated with increased malodorous gray discharge

(+) "Wh_iff'test

-may be frothy -treatment options -metronidazole 29 PO Xl -metronidazoie 500mg PO BiD X 7d -metronidazole vaginal cream BID X 5d -ciindamycin vaginal cream QD X 7d

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2)Trichomonal Vaginitis -caused by Trichomonas vaginalis -presents with vaginal pruritis and a malodorous frothy, yellow-green discharge -cervical petechiae ) strawberr.y cervix -trichomonads are seen on wet prep -treat with metronidazole 29 PO Xl -check for other STIs -treat partners and educate to refrain from sex until infection treated

I X \use3)Chlamydial Urethritis / Cenricitis -caused by Chlamydia trachomatis

-most common STD -75-90% of cases are asymptomatic recommended to screen all women <25 yrs and in other asymptomatic women at increased risk -presentation depends on sex -men present with urethral discharge of mucopwulent / purulent materiaf dysuria, or urethral pruritis -accounts for 35-50% ofcases ofnongonococcal urethritis -women present with uethritis, bartholinitis, cervicitis characterized by dysuria, abnormal vaginal discharge, or post-coital bleeding -may also present with upper genital tract infections (endometritis, salpingo-oophoritis, or PID) characteruedby irregular uterine bleeding and abdominal / pelvic discomfort Note: both sexes can present with reactive arthritis / tenosynovitis or Reiter's syndrome (urethritis, conjunctivitiso arthritis, & mucocutaneous lesions) -diagnose with PCR or LCR of discharge or wine -sensitivity 80-91% (range depends on type of material collected) -specificity 95-1A0% -new home kits based on this technology are available -treat with azithromycin 19 PO Xl -check for other STIs -treat parlners and educate to refrain from sex until infection treated

\ 4)Lymphogranuloma venereum t St"a-" OH\an^v -caused by Chlamydia trachomalls serovars Ll-L3 -starts as a painless mucosai lesion ) lyrrphatic spread
I'zld

J"

inguinal bubo

draining sinus tracts -treat with do>rycycline 100mg BID PO -check for other STIs -treat partners and educate to refrain from sex u:rtil infection treated

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5)Gonotlhea
-caused by Neis s eria gonomhoeae (GN-diplqgocd -can infect any mucocutaneous surface (oral, urethnal, vagina[ anal) -presents with yellow, creamy, profuse discharge

perihepatic gonorrhea -Fitz-Hugh-Curtis syndrome -present with fever & RUQ pain peritoneum & liver capsule -extension of infection from fallopian tubes -diagnose with LCR of discharge or urine -treat I25mgIM Xl or FQ plus azithromycin 1g PO Xl empiricaily treat chlamydia also -check for other STIs -treat partners and educate to re ain from sex until infection treated

Cf| = Rr;Ccpvr,ne
6)Human Papillomavirus -HPV causes genital warts and cervical / anorectal dysplasia / neoplasia -HPV 6 and 11 most commonly cause external genital warts ) low risk for rg = LtL,t: RISV< neoplasia LU$ r* -HPV 16, 18, 31, 33, 35 most common for cervical dysplasia * high risk -appear as an exophytic growth, often pink or white -solitary lesions or clustered lesions -usualiy not painful, pruritis common -anorectal warts = condylomata acuminata l-atA -diagnose with biopsy -treat with ablation, imiquimod (Aldara), podofilox, or TCA -check for other STIs

Pt \sy 7)Herpes Simplex Virus -HSV predominantly causes oral / genitdl ulcers -HSV-I oral (can cause genital) -cold / fever sore -85% of US population has serologic evidence -HSV-2 genital (can cause oral) -25% of US population has serologic evidence -genital ulcers present as grouped, pain-firl vesicies -fever, adenopathy, and urinary s;nnptoms possible -outbreaks often recurrent (remain dormant in sensory ganglion) -new guidelines recommend culture to differentiate HSV-1 from HSV-2 -HSV-2 much more likely to have recurrent lesions

'R*.\'s'

-can also cause

-ocular disease -meningoencephalitis -esophagitis / proctitis -HSV-i is associated with Bell's Palsy

13

-clinical diagnosis confirmed with Tzanck smear, DF,\ serology, PC& or culture intranuclear inclusions & multinucleated giant celis -Tzanck -PCR important for CSF studies -treat with acyclovir, valacyclovir, or famciclovir -6/yr. try suppressive therapy -treatment does not eradicate disease -check for other STIs -valacyclovir (Valtrex) approved for decreasing risk of transmission

8)Chancroid
-caused by Haemophilus ducrey,

.\t

fV )

-GN coccobacillus

with fluctuant inguinal adenitis -treat with ceftriaxone 250mg IM Xl or azithromycin 1g PO Xl -check for other STIs
-painfi.rl genital ulcer (chancre)

9)Granuloma

inguinale

*'hrn**rri,"r!*b(:r}'g\

-caused by Calymmatobacterium granulomatis

-chronic, relapsing, granulomatous anogenitai infection -painftl infiltrated nodules uicer with red &iable base of granulation tissue -diagnosis: Donovans bodies seen on $/right or Giemsa stains -treat with doxycycline 100mg PO BID X 21d or TMP-S}vD( DS PO BID X 3-4 wks. -check for other STIs

l0)Syphilis'Jertc-hr}

"Teczl1nr

-.tle4,wtrh jienici[in> -gpe of penicillin and duration oftreatment depend on stage of syphilis -check for other STIs

-caused by Trepanema pallidum -clinical stages -Primary syphilis (painless ulcer at site of exposure : chancre) -Secondar.y syphilis (generalized maculopapular rash (even palms / soles) -Tertiary syphilis (infiltrative tumors (gummas), aortitis, neurosyphilis) -diagnosis -screening: VDRL or RPR -confrmatory: ETA:ABS or MHA-TP -more sensitive & specific :qlays positive for life

1,4

{)Molluscum Contagiosu\

-.-.'-.-.'.---..=..

-caused by an unclassified poxvirus -can be acquired by direct contact (including sexually) or by contact by infected

materials (i.e. towels) -lesions begin as papules pearly, umbilicated nodules 2-10mm in diameter, with a central caseous plug that can be readily expressd -lesions are most corxron on trunk, genitalia, and proximal extremities and are typically in a cluster of 5-20 nodules -treatment -mild disease will resolve on their own 2-12 months after development even without treatment) -extensive or disfiguring disease ablative therapy (i.e.liquid nitrogen, laser)

fiY = I2)PeMc Inflammatory Disease (PID) -PID is a term used to describe ascending infection of the endometriurn, faliopian

b"t\ tta^Li\

Lp<>v'n1

tubes, and other peivic structures -i.e. describes salpingitis, tubo-ovarian abscess, pelvic peritonitis, and

1r,-\ .v \ t - I .+ r *

^n t\ \'

-i^ n.)F /2 Y rz'

\ c, '-'

endometritis -risk factors include multiple sexuai partners, frequent sexual partners, and new sexual parlners within the last 30 days -po lynicrobial infectio n (l{. Sgf-rrr ho e a e, C-,Xsehenati s, My c opl as m a Ur e apl as ma, Enter ob act eriac e ae, mixed anaerobes and siraptococci; -present with lower abdominal pain, adnexal / cervicai motion tenderness mmrmum crrterra -fever and vaginal discharge also possible -diagnosis is really ciinical with supportive lab tests / imaging -laboratory findings are nonspecific (leukocytosis) -US to rule out tubo-ovarian abscess -laparoscopy most sensitive method of diagnosis perform if diagnosis uncertain

15

-Selected

1)d;eoffi

elt&Edic

Infections

-infla:nmation of the bone / bone ma:row -hematogenous seeding conrmon in children -most commonly metaphysis of iong bones -contiguous spread common in adults -often from a soft tissue infection (i.e. DM ulcer) -S. azreus is most common overall cause (esp. hematogenous) -contiguous-focus is oft en poiymicrobial -Salmazrel/a spp. more common in sickle cell patients -presentation is variable depending on site of infection -diagnose with iabs, imaging (nay, bone +/- WBC scans, CT, or MRI), and bone biopsy with histopathology and cultures -always r/o tumor -treat with ABX and surgery

2)Infectious Arthritis -inflammation of a joint from a pyogenic organism from a transient bacteremia

rpresent with single, hot, swollenjoint -rlo rheumatic disease -diagnose with joint aspiration -l[ gorzorrftoea most common cause in young. sexually active people -represents dis semi4alg[gggo co ccal disease (DGI) -present with feverfmigralgglpolyarlhralgias, tenosynovitis, and dermatitis -find primary gonococcal focus -treatment depends on organism

f\-r., uUlri! 't

ni,r.f i
1,,1
11Ll

-{Yri-r'\L\.{:'

16

I Endocarditis (SBE) -microbial infection of the lining ofthe heart characteristic lesion is a vegetation, which is most commonly found on vaivular structures -etiologic F-.:.r -native valve: f,riridanslstrep, S. aureus, and Enterococci -prosthetic valve early infections (<2 months after valve) ;-coagglasq(-) staph

agents

-Iate infection: resembles native vaive -other organisms (HACEK) -Haemophilus p ar ainfluenzoe / aphr ophilus -Actino b acillus actinomycet emc omitans -C ar di o b act er ium homini s -Eikenella corredens C.l - t<;n -c\\a) -Kingella bingae -often present with febrile illness lasted for days to weeks, often with nonspecific symptoms (cough, dyspne4 arthralgias, diarrhe4 abdominal / flank pain -90% have murmurs (development of CFIF is most common complication and death from SBE) -40% have systemic emboli (spleen ) renal > cerebral / ophthajmic / mesenteric / coronary) -25% have characteristic peripherai lesions -petchiae of paiate, coqiunctiv4 beneath fingemails -subungal (splinter hemorrhages) - 7 Llrr<\r:r Wc,.', \ -Osler nodes (painful, violaceous raised lesions of fingers / toes) -Janeway iesions (painless erythematous lesions of palms / toes) -Roth's spots (retinal exudative lesions) -diagnose withblood cultures, EKG, CXR, labs (CBC, ESR UA), echo (TEE more sensitive than TTE) -Duke Criteria is used for diagnostic criteria -treatment -empiric therapy i)nafciliin + ampicillin + gentimicin OR 2)vancomycin + gentimicin

l-E6*,d'

t7

2)Pericarditis
-acute inflammation of the pericardium -may be infectious (echoviruses & coxsackieviruses) or systemic disease (AMI, neoplasnr, radiation" sarcoid, lupus, IBD, medications) -typicatly present with chest pain, often pleuritic and postural

-often relieved by sitting and leaning forward) -pericardial friction rub is classic -EKG shows generalized ST & T wave changes ) begin with diffirse ST elevation followed by return to baseline & then T wave inversion -treatment is multifactorial -NSAIDS or prednisone for s1'rnptomatic relief -identify and treat the cause

3)Acute Rheumatic Fever (RF) -the nonsupportive complications of S. pyogenes (GAS) infection are acute rheumatic fever and acute glomeruionepluitis -incidence has dramatically decreased since introduction of penicillin and improved socioeconomic status in the US -clinical manifestations are multiple, but varied and several criteria must be met to establish a definitive diagnosis -2 n:urjor manifestations or 1 major and2 minor manifestations plus evidence of antecedent GAS infection arthritis > carditis > S1'ndenham's chorea -major manifestations > subcutaneous noduies fever, arthralgias, heart block, increased -minor manifestations

WBC/CRP/ESR
-murrnurs of mitral stenosis and aortic stenosis are cluonic , manifestations of RF

ical Infections -Selected 1)Meningitis -defined by the presence of bacteria within the subarachnoid space causing inflammation with resuitant inflammatory consequences -mortaiity is organism dependent -5. pneumoniae 2AYo mortalitY -N. meningitides <lATo mortality -H. influenzae SYo mortality -transmitted by respiratory droplets or mucosa-to-mucosa spread -most organisms gain access to CNS via bloodstream and choroids spread -other routes include 1)contiguous spread (sinusitis or otitis medra) 2)post-operative infection or trauma 3)indwelling devices

18

-Classification

l)Acute Meningitis
-most cofiImon, medical emergency -rapid onset of symptoms -classified into bacterial & aseptic -"aseptic" meningitis usually indicates arboviruses (arthropod-borne) and enteroviruses (coxsackieviruses / echovirus) 2)Chronic Meningitis -symptoms may be present for months / years (ex. TB & neurosyphiiis) )Meningo encephalitis -refers to infections that involve the CSF, leptomeninges, and brain parenchyma itself 4)Parameningeal infections -includes subdural empyema / epidural abscess I &an abscess -etioiogies depend on age of -" r.l -ra*'\'l-) -0-4 weeks S. agalactiae (GroupB strep), E. cali, ListeriafVros"-\ -4-12 weeks-) as above PLUS H. influenzae,.S' pneumoniae,
3

patient

r.

$-' .ftu' ^,li-)'

\v
.,

\J{,nslagli4qyt
-3months-lSytt

Nl'

H. inJluengpA.S. pneumoniae, N' meningitides - i 8-50yrs ) S. pneumoniae W..-usntrtgztjdeD ->50yrs ) S. pneumoniae, N. meningitides, Listeria -classic presentation include fever, FlA, neck stiffiress (85% of patients) -NA/ and variable rates of confusion are also common -check for nuchal rigidrty (turn head side-to-side, then flex and observe for discomfort) -Kernig & Brudzinski are less sensitive tests
-CSF examination is the key -check opening PSI, cell count / differential, glucose, protein, gram stain I culture -bacteriai antigen studies indicated when patients have been pretreated with ABX -CT's ofthe head are overused -When should you order a CT? anyone with increased ICP as manifested by signifieant papilledema, dilated nonreactive pupil, ocuiar motion abnormalities, drowsiness / stupor, bradycardia / HTN OIEJM 2001;345:1727-33) (for community-acquired acute meningitis) -treatment -empiric vancomycin + ceftriaxone a7- Ugp4iffial L7-ftrnct -modrfy therapy based on culture results -dexmethasone may also be added

-g*ii"'""''

l9

-Anatomic & Clinical Classification of Skin & Soft Tissue Infections Note: from Curent - Diagnosis & Treatment in Infectious Disease

p.

178

Rjp@las lrpeligo

-i\, 'S.

\' ,li
r-l 4-

t\'

rr

s*-J
-.-d :l-t -_:-l

f,W
-,r--".:::::....-.*.= _

gctarna Rrunorlssls

Fof[a$Es

(,') t

ffi ffi
i=__-g+;_ ri' -:- ---tat---

Cdlulilis

edb

l,lecrotizing

'9/
,;*
q-,i

lt{tonecrods (cbsnidal and

nondositfat)

Ts

Sqnfe

20

-Selected Skin

& Soft Tissue Infections

l)Impetigo

Peds

2)Erysipelas -infection of the epidermis / dermis

-usually caused by S. pyogenes -seen as red, gJistening, and demarcated -treat with antistaphylococcal ABX -see ABX lecture notes

(GAS)

Fe*\ dlsue .r F<eI cI&SL

3)Cellulitis
-infection of the epidermis / dermis / CT -present with F/C, erythema, and induration -ervthema is iess intense than erysipelas Ilrmon -caused by S. pyogenes or S. aureus -treat with anti-staphylococcal ABX -see ABX iectures

4)Cutaneous AbscesseS,.

* ", ;| -Folliculitis L-c'rt5 Z

-infection of the hair foilicle and apocrine glands -often on the face, buttocks, extensor surfaces -presents as small, tender, er;'thematous papuies, often topped a by central pustule -usually caused by S. aureus and topical mupiricin C ts".d'\'t\* -treat with warm

"o*pr.rr.s

")

-IIot Tub Folliculitis

-acquired from contaminated pools / hot -eaisedby P. aeluqinosa L^nsr ctrvJ.:,\\\ r*Vrl'>c'r^e' $., tendet plpgr. )- pustule -present and anti-pruritis meds -treat with warm compresses -ABX not indictated

tubs

t<'\\

!,

*itn@to-"times

t flir'J( >-t \

"TY'. cf,r,r ar ie;';*ri'"''*' ) k't\

psduLlbY]ad^t'l

-Furuncles @oils) \1U bL ?- \ f -often secondary to foliiculitis ) spreads to subcutaneous tissue -present as firm, tender, erythematous nodules that become fluctuant -common on neck, axillae, buttocks
-usually caused by S. aureus -treat with I&D and anti-staphylococcal ABX (or based on culture results)

21

-Carbuncles

-multiple abscesses separated by CT, extending into subcutaneous fat in areas ofthick, inelastic skin (neck, back, thighs) -basically a collection of furuncles -fever and constitutional slmptoms are comrron -usually caused by S. aureus -treat with I&D and antistaphylococcal ABX (or based on culture results)

frS''g,-7 (.,taner'">

Dt/
sparing

S)Necrotizing Soft Tissue Infections -Necrotizing fasciitis -infection that progressively destroys the subcutaneous fascia / fat

^b'>(

with

muscle 6rp ft sv1,{\^tot'.ir. -) C{lesr -classically caused by S. pyogenes (iff-iy 10%) +most are polymicrobiai -present like cellulites" but exam finding (s)'stemic toxicity. pain) are out of

r,r}un1)

ft;;,

proportion
-extensive debridement is key -broad-spectrum ABX are secondary

-Fournier's Gangrene
-polymicrobial necrotizing fasciitis of the scrotum +/- perineunr penis. or abdominal wall -often in diabetics -extensive debridement is key -broad-spectrum ABX are secondary

-Clostridial Myonecrosis (Gas Gangrene)

nn0sc\es -infection that progressively destroys the subcutaneous fascia, fat, and muscle -usualiy caused by C. pe$"ingens -often from traumatic wounds or enteric surgery -present acutely with severe pairl systemic toxicity, +/- crepitus -extensive debridement is key -broad-spectrum ABX are secondary

&"p:-d"

22

-Bite wound

Infections

A*r-*.sl^
of

-often from dogs (lacerations) > cats (punctures) > humans (occlusions) -infecting organisms can be from the environment, victim's skin, or the "normal" flora the biter -often polymicrobial in nature -usually caused by Staphylococcus spp., Sneptococcus spp., various anaerobes -unique organisms Pasteurella multocida -doss / cats Eikenella conodens -hvmans +/- srugery (if compiications) -treat with ABX

@o)orunasyn(IV) metronidazole -Ceffioxhe p/ars ciindamycin or

-do4ycycline or TMP-SIvD( or FQ

plus clindamycin or metronidazole

-Infectious Diarrhea -Divided nto 2 classes -Non-Inflarnmatory Diarrhea -Characterized by l)large volume, watery stool 2)no blood / PMNs 3)nausea / flu-like sym.ptoms common

-DifferentialDiagnosis

-viral infections -protozoal infections (Giardia, Crypotosporidium) -bacterial infections (5. aureus, B. cereus, V. cholera) -Anti-peristaltic agents are ok

) (Norwalk Virus, Norovirus) ( Lrvtt' 3Y"o

/r

.\
)

-l*\ t'J6rm;J,[xr'

'

-Inflaffinatory Diarrhea -Characterized by l)small volume, frequent bioody / mucosy stools 2)many PMNs 3)fever / chills and crampy abdominal pain common -Differential Diagno sis -protozoal infections (E. histolytic a) -bacterial infections (E. coli A157, C. dfficile, Shigella,

)k

-No

*?;:#';i:':;::(

*' ne

It

a)

-/.)

na

-Non-Infl ammatory Infectious Diarrhea l)Viral Infections -Norwalk Virus & Norovirus (Norwalk-like Virus) -causes "Winter Vomitinf Disease" -acquired via contaminated food I H20 or person-to-person contact -most common cause of gastroenteritis in the US -present with N/VID and abdominal pain that lasts 1-3 days -low-grade / transient fever possible -treat supportively with rehydration (ORT)

2)Protozoal Infections -Giardiasis

-caused by Giardia

lanfilia

-most common oarasitic etioloqv of infectious diarrhea in

,n.-u,
-associated rvith camping / hiking
-fecal- oral transmission -affects the SI and may oause diarrhea -most causes asymptomatic -may have acute or chronic diarrhea or a malabsorption

$Yndmne -) F rttY Gfi,D[ -diagnose with O&P & stool EIA (serology) _treat with metronidazoie _gluj\

'#

Dx e

f-t A

-Cryptosporidiosis
-caused by Cryptosporidiunt

panwn

-fecal-oral transmission -affects the colon and causes "cholera-1ike" diarrhea -self-limiting in immunocompetent patients; severe in AIDS patients -diagnose with O&P & stool EIA (serology) -treatment is based on immune status -non-AIDS : nitazoxanide -AIDS: paromomycin + azithromycin

24

3)Bacterial fnfections
- Stap

hylococcu s flurn es -exotoxin is released into a food product (mayonnaise) that is then eaten

-treat supportively

Stap^ au1 Yr.,.',jS

pld.+, s."L^,{

V.A,*tCb jn SD-bDwvlc -Bacillus cereus -exotoxin is released into a food product (rice) that is then eaten -"food-poisoning,, -treat supportively

-Cholera ( Cystc,

r'<r

t\n"'FliF.;t't" R^*\

-caused by T'ibrio cholerae -occurs in epidemics under conditions of inadequate sanitation -transmitted by contaminated food / water -presents with rice water stool -diagnose with stool culture -treat with Fe & rehydration

_-.-t_---._ *\ [ -tnflammatoryhnfectious Diarrhea

1)Protozoattnje*ions
-caused by Entamoeba histolytica -fecal-oral transmission mostiy in tropics -causes most disease in the coion / liver -colonic disease recurrent diarrhea / abdominal pain -hepatic abscesses ferrer, hepatomegaly, pain, and localized tenderness -diagnose with O&p, serology, and imaging -treat with metronidazole +/- paromo*y"io ia.pending on disease severity / state)

-&ain

abscess

if indicated

25

u (' ?So/' eF^\ \jo"')y .\""whu'-. 2)Bacterialrnfection,

-Escherichia coli O157:H7 -serot)?e of E. coli producing "shiga-toxins" -associated with undercooked hamburger, unpasteurized miik / juice, and raw fruit / vegetables -infection may be asymptomatic or present with bloody diarrhea and HUS -afebrile plus bloody diarrhea ) E.coli (until proven otherwise) -hemolytic uremic syndrome (I{US) = -ARF + thrombocylopenia + hemolytic anemia -treatment is supportive ) ABX are controversial

TX ; Abx.

&o,olo\a.,e-

-Cbnrtdium

ilfficite

]f

-produces an enterotoxin (toxin A) and a cytotoxin (toxin B) -associated with all ABX -pick ciindamycin on the boards -variety of syndromes are possible -asymptomatic infection ) diarrhea ) PMC ) toxic megacolon ) fulminant colitis -present with fever, abdominal cramping I pwn, and watery diarrhea -diagnose with stool FIA -treat *itrrffiffia"o-i6pnd place in contact isolation

$F

l'+irx

fx

-Shigellosi,

DoY Ccartl
-5. sonnei

-caused by multipie shigella species

>

S.

.flexnerz >

,S.

dysenteriae (in US)

-associated with day-care outbreaks -presents abrupti)'with biood)' diarrhea, abdominal

pai4 tenesmus,

qxicity

-Campylobacteriosis

6rnL-\ 3 sh'ry'\ rcJ

-caused by Campylobacter jejuni -presents with fever, watery-bloody diarrhea, and abdominal pain -most common bacterial cause of infectious diarrhea in the US -associated with raw / poorly cooked chicken

-treat with erychromycin

26

-Salmonellosis -salmonella species cause 2 main clinical patterns -enteric fever (,Salnonella \pht) -gastroenterrtis (Salmanella tlphinruriuw, among other
species)

-transmitted by ingestion of the organism, usually from contaminated food or drink -associated with eggs -enteric fever is a ciinical syndrome characterized by constitutional symptoms, GI syrnptoms, and by HA -any salmonella species can cause enteric fever, lcntt S' Whi is most common .9. f,.f:&l -typhoid fever: enteric fever 2' -GI symptoms may be marked constipation or "pea soup" diarrhea -rose spots may be present (2-3 mm papule on trunk usually) -treat with FQ or ceftriaxone if severe disease -vaccine available

to